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| As Death Toll in Nursing Homes Climbs, Calls to Redesign Them Grow | As Death Toll in Nursing Homes Climbs, Calls to Redesign Them Grow |
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| Shortages of safety gear and staff. Workers who may inadvertently be carriers. A disease that preys on older people with underlying health conditions. There are many reasons the coronavirus has hit nursing homes so hard. | Shortages of safety gear and staff. Workers who may inadvertently be carriers. A disease that preys on older people with underlying health conditions. There are many reasons the coronavirus has hit nursing homes so hard. |
| Add the design of the buildings to the list. | Add the design of the buildings to the list. |
| With shared resident rooms off long corridors and vast dining rooms where everyone mingles, nursing homes may have been laid out to be efficient and cost effective. But these very features have also allowed the virus to spread from person to person in what Gov. Andrew M. Cuomo of New York called “a feeding frenzy.” | With shared resident rooms off long corridors and vast dining rooms where everyone mingles, nursing homes may have been laid out to be efficient and cost effective. But these very features have also allowed the virus to spread from person to person in what Gov. Andrew M. Cuomo of New York called “a feeding frenzy.” |
| Since the country’s first sizable outbreak in a nursing home in Kirkland, Wash., the coronavirus has made its way into 7,500 long-term care facilities, killing dozens at some. Across the country, more than 143,000 of their residents and workers have contracted the illness and more than 25,600 have died, according to a New York Times analysis. That is more than a third of the deaths from the pandemic. | Since the country’s first sizable outbreak in a nursing home in Kirkland, Wash., the coronavirus has made its way into 7,500 long-term care facilities, killing dozens at some. Across the country, more than 143,000 of their residents and workers have contracted the illness and more than 25,600 have died, according to a New York Times analysis. That is more than a third of the deaths from the pandemic. |
| In New York State, a pandemic hot spot, “why are we seeing such a high rate in nursing homes?” asked Richard J. Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for residents. “Maybe it’s because some nursing homes are so big.” | In New York State, a pandemic hot spot, “why are we seeing such a high rate in nursing homes?” asked Richard J. Mollot, executive director of the Long Term Care Community Coalition, an advocacy group for residents. “Maybe it’s because some nursing homes are so big.” |
| Many of the 15,400 nursing homes across the country are laid out like hospitals, and some house hundreds of residents. Most rooms are double occupancy, but some have three or even four residents. | Many of the 15,400 nursing homes across the country are laid out like hospitals, and some house hundreds of residents. Most rooms are double occupancy, but some have three or even four residents. |
| Before the pandemic, a movement under the banner of “culture change” was challenging this institutional model, calling for dividing up large nursing home populations into small, self-sufficient units with kitchens, private rooms and a dedicated staff. | Before the pandemic, a movement under the banner of “culture change” was challenging this institutional model, calling for dividing up large nursing home populations into small, self-sufficient units with kitchens, private rooms and a dedicated staff. |
| “Rather than a long hallway with 40 rooms and 80 or more residents, you have these spots with more like 16 residents,” Mr. Mollot said. | “Rather than a long hallway with 40 rooms and 80 or more residents, you have these spots with more like 16 residents,” Mr. Mollot said. |
| This type of arrangement has been set up in multistory buildings with, for example, a couple of households per floor and in single-story purpose-built structures with homelike interiors. | This type of arrangement has been set up in multistory buildings with, for example, a couple of households per floor and in single-story purpose-built structures with homelike interiors. |
| But this model can be more expensive. Households with private rooms take up about 10 percent more space than conventional interiors with shared rooms and cost $15,600 more per bed, said Perkins Eastman, an architecture firm with an active health care facility practice. | But this model can be more expensive. Households with private rooms take up about 10 percent more space than conventional interiors with shared rooms and cost $15,600 more per bed, said Perkins Eastman, an architecture firm with an active health care facility practice. |
| The cost of building a skilled nursing facility in the last 10 years ranged from $223 to $361 per square foot, according to data based on an index of 100 cities compiled by the National Investment Center for seniors and Housing Care, one of the main data service providers for the elder care industry. | The cost of building a skilled nursing facility in the last 10 years ranged from $223 to $361 per square foot, according to data based on an index of 100 cities compiled by the National Investment Center for seniors and Housing Care, one of the main data service providers for the elder care industry. |
| So far, an estimated 10 to 15 percent of nursing homes in the United States are set up this way. This smaller-is-better approach arose out of a concern for residents’ privacy and dignity, but evidence is emerging that it may also be helping with infection control. | So far, an estimated 10 to 15 percent of nursing homes in the United States are set up this way. This smaller-is-better approach arose out of a concern for residents’ privacy and dignity, but evidence is emerging that it may also be helping with infection control. |
| A private room or even an entire household can be closed off more easily, keeping out or confining viruses. Staff members who are focused on a small number of residents may be more likely to pick up on warning signs, such as a lack of appetite, that someone is sick. The preparation of food and laundry in a household — rather than in central facilities and then distributed — also eliminates a few of the ways diseases can infiltrate. | A private room or even an entire household can be closed off more easily, keeping out or confining viruses. Staff members who are focused on a small number of residents may be more likely to pick up on warning signs, such as a lack of appetite, that someone is sick. The preparation of food and laundry in a household — rather than in central facilities and then distributed — also eliminates a few of the ways diseases can infiltrate. |
| No design, without accompanying operational measures, is a bulwark against disease, and studies have yet to be done comparing the number of cases and deaths at small-house nursing homes and those at conventional ones. But anecdotal reports suggest that private rooms may be having more success at keeping the coronavirus at bay. | No design, without accompanying operational measures, is a bulwark against disease, and studies have yet to be done comparing the number of cases and deaths at small-house nursing homes and those at conventional ones. But anecdotal reports suggest that private rooms may be having more success at keeping the coronavirus at bay. |
| That is the conviction of the Green House Project, a nonprofit organization that oversees 266 small-house nursing homes. Of the 243 projects that supplied data in early May, eight reported having cases of Covid-19, the disease caused by the coronavirus, and there were no deaths, said Susan Ryan, the organization’s senior director. | That is the conviction of the Green House Project, a nonprofit organization that oversees 266 small-house nursing homes. Of the 243 projects that supplied data in early May, eight reported having cases of Covid-19, the disease caused by the coronavirus, and there were no deaths, said Susan Ryan, the organization’s senior director. |
| “From a design perspective, this has only reinforced what we thought was a good idea,” she added. | “From a design perspective, this has only reinforced what we thought was a good idea,” she added. |
| The Department of Veterans Affairs began embracing a small-house model in 2011; now, 13 of its 134 nursing homes are organized around communities of 10 to 14 residents. In these settings, only a single veteran has tested positive for Covid-19, Christina Noel, a V.A. spokeswoman, said in a statement. | The Department of Veterans Affairs began embracing a small-house model in 2011; now, 13 of its 134 nursing homes are organized around communities of 10 to 14 residents. In these settings, only a single veteran has tested positive for Covid-19, Christina Noel, a V.A. spokeswoman, said in a statement. |
| Private rooms have made a “huge” difference in the ability to control the virus at Jewish Senior Services, a four-story building for skilled nursing and assisted living in Bridgeport, Conn., said Andrew H. Banoff, president and chief executive of the organization. There are 330 residents divided into households of 14 residents each. | Private rooms have made a “huge” difference in the ability to control the virus at Jewish Senior Services, a four-story building for skilled nursing and assisted living in Bridgeport, Conn., said Andrew H. Banoff, president and chief executive of the organization. There are 330 residents divided into households of 14 residents each. |
| “When somebody is diagnosed, their door is closed,” Mr. Banoff said. Signs are posted and safety gear is placed outside the door so that staff know to suit up before entering. | “When somebody is diagnosed, their door is closed,” Mr. Banoff said. Signs are posted and safety gear is placed outside the door so that staff know to suit up before entering. |
| Still, the coronavirus has cropped up in eight of the 23 households, 15 residents have died, and four staff members have been hospitalized, he said. | Still, the coronavirus has cropped up in eight of the 23 households, 15 residents have died, and four staff members have been hospitalized, he said. |
| Administrators of nursing homes large and small, as well as the architects who renovate and design their facilities, expect to zero in on disease control in the future as a result of the pandemic. Air circulation and filtration will be scrutinized when heating, ventilation and air conditioning systems are planned, they said. | Administrators of nursing homes large and small, as well as the architects who renovate and design their facilities, expect to zero in on disease control in the future as a result of the pandemic. Air circulation and filtration will be scrutinized when heating, ventilation and air conditioning systems are planned, they said. |
| Updated June 30, 2020 | |
| Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. | Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days. |
| Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles. | Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles. |
| A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico. | A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico. |
| The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth. | The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth. |
| The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave. | The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave. |
| So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. | So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement. |
| Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. | Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks. |
| A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. | A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study. |
| The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April. | |
| If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) | If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.) |
| If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. | If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others. |
| “I’ll be paying more attention to the HVAC piece of it,” said John Shoesmith, a Seattle architect who specializes in senior living design. | “I’ll be paying more attention to the HVAC piece of it,” said John Shoesmith, a Seattle architect who specializes in senior living design. |
| The Facility Guidelines Institute, which writes planning and design standards that are adopted in most states and by federal agencies, set up a task force this month to make recommendations for how health care facilities can cope during emergencies. Douglas S. Erickson, the institute’s chief executive, said the task force would produce a white paper for public review by the end of the summer and publish new standards in January 2022. | The Facility Guidelines Institute, which writes planning and design standards that are adopted in most states and by federal agencies, set up a task force this month to make recommendations for how health care facilities can cope during emergencies. Douglas S. Erickson, the institute’s chief executive, said the task force would produce a white paper for public review by the end of the summer and publish new standards in January 2022. |
| But some providers are not waiting. | But some providers are not waiting. |
| Evermore Senior Living is wrapping up construction on the first of 12 small houses for assisted living and memory care in Woodbridge, Va. Dave Risi, the owner operator, said the first building, which will contain three households of eight residents each, will open in July. Because of the coronavirus, he is now ramping up air filtration. | Evermore Senior Living is wrapping up construction on the first of 12 small houses for assisted living and memory care in Woodbridge, Va. Dave Risi, the owner operator, said the first building, which will contain three households of eight residents each, will open in July. Because of the coronavirus, he is now ramping up air filtration. |
| Mr. Risi already had high-efficiency particulate air filters, commonly called HEPA filters, which can trap bacteria and other particles. Because of the coronavirus, he is now adding ultraviolet light filters that can kill airborne viruses. | Mr. Risi already had high-efficiency particulate air filters, commonly called HEPA filters, which can trap bacteria and other particles. Because of the coronavirus, he is now adding ultraviolet light filters that can kill airborne viruses. |
| Nursing home providers and their architects are also talking about easy-to-clean, nonporous surfaces; antimicrobial materials, like copper, for “high touch” features such as hand railings; and voice- or sensor-activated controls for doors, lighting, curtains, faucets and toilets. | Nursing home providers and their architects are also talking about easy-to-clean, nonporous surfaces; antimicrobial materials, like copper, for “high touch” features such as hand railings; and voice- or sensor-activated controls for doors, lighting, curtains, faucets and toilets. |
| Even as they battle the coronavirus, some nursing home administrators are reassessing renovation plans that were in the works when the virus hit. | Even as they battle the coronavirus, some nursing home administrators are reassessing renovation plans that were in the works when the virus hit. |
| Andrus on Hudson, a nonprofit senior care community in Hastings-on-Hudson, N.Y., had hired Amenta Emma Architects to help with a renovation. Now James Rosenman, the chief executive, is talking to the designers about the possibility of installing modular walls so that resident rooms can quickly be reconfigured in a crisis. | Andrus on Hudson, a nonprofit senior care community in Hastings-on-Hudson, N.Y., had hired Amenta Emma Architects to help with a renovation. Now James Rosenman, the chief executive, is talking to the designers about the possibility of installing modular walls so that resident rooms can quickly be reconfigured in a crisis. |
| “It’s always been, ‘Do we need to move the person?’” Mr. Rosenman said, referring to how ill residents have been moved to isolation areas during the pandemic. “Maybe we can change the rooms instead.” | “It’s always been, ‘Do we need to move the person?’” Mr. Rosenman said, referring to how ill residents have been moved to isolation areas during the pandemic. “Maybe we can change the rooms instead.” |
| What is designed and built will depend on funding, of course. And nursing homes traditionally operate on the thinnest of margins. | What is designed and built will depend on funding, of course. And nursing homes traditionally operate on the thinnest of margins. |
| Most nursing home residents have their care paid for by Medicaid, according to the American Health Care Association, a provider group, but the health insurance program for the poor “is notorious for underfunding,” said Holly Harmon, vice president of quality, regulatory and clinical services, in a statement. The Trump administration recently proposed changes to the program that would allow states to cap Medicaid spending. | Most nursing home residents have their care paid for by Medicaid, according to the American Health Care Association, a provider group, but the health insurance program for the poor “is notorious for underfunding,” said Holly Harmon, vice president of quality, regulatory and clinical services, in a statement. The Trump administration recently proposed changes to the program that would allow states to cap Medicaid spending. |
| Then, too, there is the danger of designing for the current health care crisis when no one knows what the next one will bring. | Then, too, there is the danger of designing for the current health care crisis when no one knows what the next one will bring. |
| Still, many in the senior living sector hope the pandemic will spur a reckoning about design. | Still, many in the senior living sector hope the pandemic will spur a reckoning about design. |
| “If we don’t see change in the nursing home market now,” said Jane Rohde, principal at JSR Associates, a design and health care consultancy in Catonsville, Md., “I don’t know when we will.” | “If we don’t see change in the nursing home market now,” said Jane Rohde, principal at JSR Associates, a design and health care consultancy in Catonsville, Md., “I don’t know when we will.” |